Mainz II urinary diversion in low-resource settings: Patient outcomes in women with irreparable fistula in Malawi

Background Obstructed labor leading to a vesicovaginal fistula remains a devastating outcome of childbirth in low-resource countries. Women with an irreparable vesicovaginal fistula may be candidates for a urinary diversion, such as the Mainz II modified ureterosigmoidostomy procedure. Prior reviews state the procedure should be considered in low-resource countries. However, due to limited duration of postoperative follow-up, these studies do not adequately represent the long-term morbidity and mortality that is likely associated with this procedure. We present data which argues strongly against the procedure in low-resource countries. Objective (s) The purpose of the study is to evaluate the postoperative status of the patient (dead, alive, lost to follow-up) and time to death following the Mainz II procedure. Study Design This is a case series consisting of twenty-one patients who underwent a Mainz II urinary diversion from April 2013 to June 2015 for management of irreparable vesicovaginal fistula at the Fistula Care Center (FCC) in Lilongwe, Malawi. Patients were seen postoperatively at three, six, nine, and twelve months; followed by every six to twelve months thereafter. Descriptive statistics were performed to summarize the data. Results During the postoperative period, eight (38·1%, 8/21) patients died, five (23·8%, 5/21) were lost to follow-up, and eight (38·1%, 8/21) are currently alive and follow-up at the Fistula Care Center (FCC). We strongly suspect seven of the eight deaths were related to the procedure due to the patients having illnesses that exacerbated the metabolic consequences of the procedure. The eighth patient died after being attacked by robbers. Unfortunately, the exact cause of death could not be determined for these patients. Given that most of the suspected illnesses would be treatable in an otherwise healthy patient, even in this low-resource setting, we surmised that the metabolic compromise from the Mainz II procedure likely contributed to their untimely death. The average time from procedure to death was 58 months, with the earliest death at ten months and the most recent at seven years post-procedure. Conclusions The Mainz II procedure is an option for patients with irreparable fistula. However, it should likely not be performed in low-resource countries due to long-term complications that often cannot be adequately addressed in these settings, lead to significant morbidity and mortality.